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Below are some commonly used terms in the health insurance world. This glossary will help you understand some of the phrases you'll see when applying for insurance or reviewing your plan documents.

A

Advance Premium Tax Credit: A premium tax credit (also called a premium subsidy) is a way to reduce the cost of your monthly insurance premium if you have a Marketplace plan. The amount of credit you get depends on your income and family size. Learn more about subsidies HERE.

Affordable Care Act (ACA): A health care law passed in 2010 that made health insurance available to more people. You might have heard this called Obamacare. To learn more about the ACA, watch this 2-minute summary video HERE.

Allowed Amount: This is the maximum amount your health plan will pay a provider for a covered service. In other words, this is the negotiated price your insurance company agreed upon with your doctor's office. You may see this amount listed on your medical bill.

Ambulatory Care: This is also called outpatient care—medical services you get without being admitted to a hospital. Physical exams, standard doctor appointments, and same-day surgeries are all types of ambulatory care.

B

Benefits: These are the services covered by your plan, like medical care, prescription drugs, or mental health treatment.

Broker: A licensed professional who can help you find the right health insurance for you and your family. They can guide you through the process and answer any questions you have (at no cost to you). Find a local broker HERE.

Bronze Health Plan: One of the four categories (or "metal levels"), you can choose in the Health Insurance Marketplace. Bronze plans have the lowest monthly premiums but high deductibles. They are a great choice for healthy people who don't need a lot of medical care.

C

Care Management: A service offered by health plans at no additional cost to help you coordinate your care, monitor your health, and connect you to resources you may need. Your health plan may have many different types of care management programs.

COBRA: This stands for Consolidated Omnibus Budget Reconciliation Act of 1985. This law allows you to keep your job's insurance plan for a short time, even if you lost coverage because of reduced work hours, termination of employment, becoming eligible for Medicare, or other reasons.

Claim: A request to your insurance company that outlines the care you received and how much the insurance company should pay for those services. Claims are usually submitted by your health care providers, but you may submit claims on your own in certain situations.

Copay: Also called a copayment. These are fixed amounts you pay each time you get a certain medical service. For example, each time you see a specialist, you might pay a $50 copay. An important thing to remember is that copays usually don’t count toward your deductible. 

Coinsurance: A percentage of your bill that you pay after you have paid your yearly deductible. Let's say you have a 20% coinsurance, for example. That means once you have met your deductible, you pay 20% of the bill and your insurance pays the remaining 80%.

Cost-Sharing Reduction (CSR): A discount program that reduces the cost of your cost-sharing responsibilities (that's your copya, coinsurance, and deductible. You can qualify CSR based on your income and family size when you have a Silver Marketplace plan, or if you are a member of a federally recognized tribe. Learn more about CSRs HERE.

Cost Sharing: This refers to the way you and your insurance company split the cost of your health care. Some of the ways that you pay for your part include copays, coinsurance, and deductibles.

CPT Code: CPT stands for "current procedural terminology." These codes are like a universal language that doctors and insurance companies use to describe a service they provide. For example, 90658 is the code for a flu shot. You ask your doctor and insurance company about different CPT codes to see how much a service will cost.

CHIP (Children's Health Insurance Program): CHIP is a health program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. Watch a short video about CHIP HERE.

D

Deductible: This is how much you must pay for health care services out of your own pocket before your health plan will pay. After you meet your deductible, you'll usually only pay your copays and coinsurance. Your health plan will usually cover the rest.

Department of Workforce Services (DWS): A department of the Utah Government that manages eligibility for programs like Medicaid, unemployment, food stamps, disability, and others. Learn more about services HERE.

E

Effective Date of Coverage: The day your health plan starts. In most cases, any medical care you receive before your effective date will not be covered by your health insurance.

Employer Plan: Health insurance you get through your job. Your employer will usually help you pay for your monthly premium as part of your employee benefit package. This is also called a group plan.

Essential Health Benefits: These are services health plans must cover under the Affordable Care Act, including ambulatory (outpatient) care, emergency services, hospitalizations, lab services, mental health services, pediatric care, pregnancy, maternity, and newborn care, prescription drugs, preventive and wellness services, and rehabilitative services.

Exchange: Another term for the Health Insurance Marketplace®. This is where you can shop for individual and family plans if you don't get insurance through your job or qualify for Medicaid, CHIP, or Medicare.

Exclusive Provider Organization (EPO): A type of health plan where medical services are covered only when you get them from the health plan's exclusive list of providers, with an exception for emergency medical care.

Explanation of Benefits (EOB): After your doctor visit, you’ll get a document from your insurance called an Explanation of Benefits, or EOB. It’ll explain the services you got, how much your doctor charged for them, how much your insurance pays, and how much you owe. THIS IS NOT A BILL. It’s more like a summary of how your health insurance worked.

F

Federal Poverty Level: A measure of income that the federal government calculates each year to determine how much money a family needs to pay for their basic needs and be financially stable.

Flexible Spending Account (FSA): A medical savings account you can get with some job-based health plans. You decide how much money you want taken out of your paycheck and put into this savings account. You can use it throughout the year, but any money left over will not roll into the next year. 

Formulary: A list of medications that your health insurance plan covers. This can also be called a drug list or drug formulary.

G

Gold Health Plan: One of the four categories (or "metal levels"), you can choose in the Health Insurance Marketplace. Gold plans usually have higher premiums, but will cost less when you get medical care. Gold plans are great for people who have chronic conditions or need regular medical care.

Group Health Plan: Also called a job-based or employer health plan. This is health insurance you get through your job.

H

Health Insurance: Health insurance is a way to get help paying for your health care expenses. These expenses could include prescription medications, doctor visits, hospital stays, or even surgeries. Health insurance also helps you stay healthy through wellness programs and other benefits.

Health Maintenance Organization (HMO): A type of health plan that limits coverage to providers in the HMO network. Care from out-of-network providers will not be covered except in emergencies. HMO plans also require your care to be coordinated through a primary care provider (PCP) who can refer you to specialty services as needed.

Health Savings Account (HSA): A type of medical savings account that you can only get when you have a high deductible health plan. You can put pre-tax dollars into this account and use the money for medical expenses. Unlike a flexible savings account, the money in your HSA doesn't expire at the end of the year. Learn more about the difference between HSAs and FSAs HERE.

High Deductible Health Plan (HDHP): A plan with a high yearly deductible. These plans usually cost less per month, but you'll pay more when you need care. These plans are best for people who are generally healthy and don't go to the doctor often.

I

Individual and Family Plan: Individual and family plans are health insurance that individuals or families can buy on their own. These plans are available directly from insurance companies or through the Health Insurance Marketplace. Learn more about individual plans HERE.

In-Network: A term that refers to providers who have contracted with your health insurance company to offer you medical services. Your health plan has the highest benefit when you go to in-network providers and facilities.

Inpatient Care: Health care that you get when you are admitted to a hospital or other care facility for an overnight stay or longer.

J

Job-Based Health Plan: This is health insurance you get through your job. Your employer will usually help you pay for part of your insurance premium as part of your benefit package. These are also called employer or group plans.

M

Marketplace: The Health Insurance Marketplace is an online shopping tool to help you buy and compare Individual and Family health plans in your area. The federal government created the Marketplace as part of the Affordable Care Act (ACA) in 2010. You might have also heard this called Obamacare.

Medicaid: A free or low-cost health plan for low-income people and families. Medicaid can also be available to pregnant and elderly people, or those with certain disabilities.

Medicare: A federal health insurance program for people who are 65 and older (and some younger people with certain disabilities). 

Medicare Advantage: A type of Medicare plan offered by private companies that gives you additional benefits (like prescription drug coverage) that aren't covered under traditional Medicare.

Metal Levels: These are the categories of health plan you can buy in the Health Insurance Marketplace. The four options are Bronze, Silver, Gold, and Platinum.

myCase: myCase is an online platform where you can apply for and manage your benefits like Medicaid or CHIP. Visit jobs.utah.gov/mycase to get started.

N

Network: A group of medical providers and facilities that your insurance company has contracted with to provide you covered medical services.

O

Open Enrollment: A yearly opportunity to change or update your insurance plan. The open enrollment period usually lasts for several weeks to give you and your family plenty of time to make the right decision about your health insurance. Learn more about open enrollment HERE.

Out-of-Network: A term that refers to the doctors, facilities, and other health care providers who have not contracted with your insurance company to provide medical services. Your costs will be higher if you get care out-of-network.

Out-of-Pocket Maximum: A limit that your insurance sets for how much money you will actually pay in a year for health care. Your copay, deductible, and coinsurance all count toward this out-of-pocket maximum. Premiums and expenses paid toward services that aren’t covered under your insurance plan are not included in your out-of-pocket total.

Outpatient Care: This is most medical care you get. It includes doctor visits, same-day surgeries, and other medical services that don't require you to stay in a hospital or long-term facility.

P

Platinum Health Plan: One of the four categories (or "metal levels"), you can choose in the Health Insurance Marketplace. Platinum plans are the most expensive plans, but they also cover the most of your costs when you get medical care. A platinum plan might work for you if you need a lot of medical care and are comfortable paying a high monthly premium, knowing nearly everything else will be covered.

Point-of-Service (POS) Plan: POS plans are less common. You'll need a referral from your primary care provider to see a specialist, but you can get care out-of-network if you want to pay a higher price.

Pharmacy Benefit Manager (PBM): A third-party company that your insurance may work with to process all of your pharamcy claims.

Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers to offer you services. You'll pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost. You can also see most specialists without a referral from your primary care provider.

Premium: A payment you make each month for your health insurance plan. Think of it like an electricity bill or gym membership fee—it’s what keeps your health insurance plan active and working. Your premium helps cover things like prescription medication, procedures, and doctor visits.

Premium Tax Credit: A premium tax credit (also called a premium subsidy) is a way to reduce the cost of your monthly insurance premium if you have a Marketplace plan. The amount of credit you get depends on your income and family size. Learn more about subsidies HERE.

Primary Care Provider: A health care professional that you see for most of your health needs, like a family doctor or pediatrician. They get to know you, your health, and your medical history, and they can refer to you specialty care when you need it.

Prior Authorization: The process of getting approval from your health plan before getting certain types of medical care, like a hospital visit or a complex test. This is also called a preauthorization

Q

Qualifying Life Event: A big change in your life (like getting married or having a baby) that can make you eligible for a special enrollment period to change your insurance.

R

Referral: A written authorization from your primary care provider to request that you get care from another health care professional (usually a specialist).

S

Silver Health Plan: One of the four categories (or "metal levels"), you can choose in the Health Insurance Marketplace. Compared to Bronze plans, Silver plans have a slightly higher monthly premium and a lower annual deductible. Many people qualify for extra savings on Silver plans. These are called cost-sharing reductions. Your eligibility for these savings is based on your household income. Silver plans are a popular option for many people.

Special Enrollment: The time when you can sign up for health insurance outside the standard open enrollment period. Usually a major life change, called a Qualifying Life Event, can trigger a special enrollment. 

Subsidy: A subsidy (also called a premium tax credit) is a way to reduce the cost of your monthly insurance premium if you have a Marketplace plan. The amount of credit you get depends on your income and family size. Learn more about subsidies HERE.

Summary of Benefits and Coverage (SBC): A summary of your plan's costs and coverage for different types of medical services. You can use SBCs to compare plans.

U

Utilization Management: This is how your health plan monitors the type and amount of care you're getting to make sure it's medically necessary. 

Z

Zero Cost Sharing Plan: A type of Marketplace plan available to some American Indians and Alaska Natives based on income. People on these plans don't have coinsurance, copays, or deductibles when getting essential health benefits.

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